Rezecția bipolară – o tehnică mereu actuală

Geavlete B, Geavlete P
Spitalul Clinic de Urgență Sf. Ioan București – Departamentul Urologie
UMF Carol Davila București – Facultatea de Medicină

Introducere

Transurethral resection of the prostate (TURP) is considered the gold standard for male lower
urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) [1].
Bipolar techniques were very popular at the beginning because of the short learning curve [2]
from TURP to TURisP and because of working in a saline environment, that avoiding post-
TUR syndrome [3]. During bipolar resection, the energy is confined between an active
(resection loop) and a passive pole situated on the resectoscope tip. Prostatic tissue removal is
identical to M-TURP but B-TURP requires less energy/voltage [4].

Tehnica operatorie

Bipolar resection presents many option for the effective resection of the prostate: the most
similar with m-TURP is represented by the loop resection, then transurethral vaporisation of
the prostate (B-TUVP) which is derived from plasmakinetic B-TURP and utilised a high-
frequency generator and a bipolar electrode to create a plasma effect able to vaporise prostatic
tissue [8]. The “button” displaying a plasma corona on its’ surface produces a gradual, layer-
by-layer BPH bulk removal, beginning from the mucosa surface (Fig. 1) and continuing down
to the prostatic capsule until its’ muscular fibres become clearly visible (Fig. 2) [13, 14].
The procedure finishes with the anterior lobe vaporization at 12 o’clock and the apical tissue
removal around the veru montanum (Fig. 4) [15]. Another type of bipolar intervention on the
prostate is represented by the enucleation. The procedure starts with resection at the 12
o’clock position, then at the 5 and 7 o’clock positions, laterally to the verumontanum, to
enucleate the lateral lobes of the prostate. Next, mucosa at the apical adenoma is incised
circumferentially. Both lateral lobes and the middle lobe are dissected off the surgical capsule
in a retrograde fashion from the apex towards the bladder, with arrest of bleeding.
Rezultate

Concerning the efficiency, the last large meta-analysis which included a total of 69 RCTs
(8517 enrolled patients), during 12 months evaluating bipolar devices, showed no significant
difference between B-TURP and M-TURP on IPSS, QoL score, PVR, and prostate volume.
B-TURP procedures, however, seemed to be associated with a higher Qmax. However, the
study concluded that supplemental evidence is needed to compare the PVP 180W XPS device
and modern competitors (including B-TURP and HoLEP). HoLEP became the standard
enucleation technique, with satisfactory midterm results and a low complication rate [5].
Mamoulakis et al. found no differences in short-term urethral stricture/BNC rates, B-TURP
being preferable due to a more favourable peri-operative safety profile (elimination of TUR-
syndrome; lower clot retention/blood transfusion rates; shorter irrigation, catheterisation, and
possibly hospitalisation times) [6]. A comparative evaluation of the effects on overall sexual
function, quantified with IIEF-15, showed no differences between B-TURP and M-TURP at
twelve months follow-up (erection, orgasmic function, sexual desire, intercourse satisfaction,
overall satisfaction) [7]. If we refer to the main post-operative parameters (IPSS, Qmax,
OoL), there are medium-term studies but less long-term studies about each of these three
methods: bipolar resection, bipolar plasma vaporization and bipolar plasma enucleation.
Regarding the bipolar resection, Chen et al. showed similar functional results (on IPSS,
Qmax, and QoL score) for B-TURP and HoLEP after 2-yr follow-up in a large RCT including
280 patients, with HoLEP associated with shorter catheterization and hospitalization durations
and lower risk of bleeding [23].

Concluzii

Overall, according to EAU 2019 Guidelines and based to long term studies, it could be
observed nowadays that bipolar-TURP represents a viable alternative to M-TURP in patients
with moderate to-severe LUTS secondary to BPO, with similar efficacy but lower peri-
operative morbidity.

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